For discussion and debate about the ethics of health care organizations and the wider health system.

Wednesday, December 22, 2010

A Worthy Conflict about Abortion in Arizona

The level of public debate about health care ethics has been in a sorry state in recent years, as evidenced by the Kaiser Family Foundation finding that thirty percent of seniors still believe the health reform law lets a government panel ("death panel") make decisions about end of life care.

In contrast, the Arizona "theological showdown" over abortion that I posted about last week addresses profound ethical issues with admirable clarity.

In November 2009 St. Joseph's Hospital in Phoenix performed an abortion on a patient who was (a) 11 weeks pregnant and (b) terminally ill with pulmonary hypertension, a condition made much worse by pregnancy. The hospital concluded it could not save both mother and gestating child. After consultation with patient, family, caregivers, and ethics committee, the abortion was performed.

Bishop Olmsted demanded that St. Joseph's acknowledge by December 21 that it had violated ethics and Catholic teachings and promise never to repeat what it had done. The hospital refused. In a terse statement the Bishop concluded that St. Joseph's "no longer qualifies as a 'Catholic' entity...[and] may not use the name Catholic or be identified as Catholic in the Diocese of Phoenix."

The leadership of St. Joseph's Hospital and Medical Center in Phoenix is saddened today following Bishop Thomas Olmsted's announcement that he has revoked his endorsement of the hospital as "Catholic." At his direction, the hospital will remove the Blessed Sacrament from the chapel and will no longer celebrate mass there.

Though we are deeply disappointed...St. Joseph's will remain faithful to our mission of care, as we have for the last 115 years...[we] will continue through our words and deeds to carry out the healing ministry of Jesus.

Consistent with our values of dignity and justice, if we are presented with a situation in which a pregnancy threatens a woman's life, our first priority is to save both patients. If that is not possible we will always save the life we can save, and that is what we did in this case...Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save.

In teaching medical ethics I always encourage the groups I work with to (a) think through what they believe is the right thing to do, (b) explain the rationale for their conclusion, and then (c) ask what the law says. Most of the time law and ethics will coincide.

If our ethical analysis and the requirements of law diverge, the first thing to do is to revisit our ethical analysis. Did we miss something? After all, law is an expression of the body politic's conclusions about how to govern itself.

If we hold to the conclusion we reached, the next question is whether we see the situation as one in which fair-minded people can disagree about right and wrong. The Bishop spoke to this in his November letter to Catholic Healthcare West, parent organization to St. Joseph's:

...you stated in a letter to me "As you know, many knowledgeable moral theologians have reviewed this case, and reached a range of conclusions. If we may assume that these individuals are motivated by their faith and desire for justice, one must at least acknowledge that this is a very complex matter, on which the best minds disagree." Thus, it would appear that your intention is to resolve our disagreement by asserting that there is no single "correct" answer to the question of whether the procedure that led to an abortion at St. Joseph's Hospital was morally permissable under the Ethical and Religious Directives of the USCCB. In effect, you would have me believe that we will merely have to agree to disagree. But this resolution is unacceptable because it disregards my authority and responsibility to interpret the moral law and to teach the Catholic faith as a Successor to the Apostles.

Catholic Healthcare West and St. Joseph's Hospital believe their interpretation of the moral law taught by the Catholic Church is correct. The Bishop claims that his position in the Church heirarchy gives him authority to decree the correct answer. It appears that Catholic Healthcare West and St. Joseph's believe that he is not infallible and has, in fact, reached a conclusion they regard as wrong and cannot accept.

To the best of my knowledge, the Bishop's claim that he has authority to decree what the correct answer to the St. Joseph's question is correct under Cannon law. But this "authority" is not persuasive to his flock - a 2009 Gallup poll showed that forty percent of Catholics regard abortion as morally acceptable. Insofar as the Phoenix case draws attention within the Church, the Bishop's action is likely to push more Catholics away from the official teaching, given that this was a situation in which holding to the official position meant death for the mother. The hospital accepted the Bishop's authority to take away their right to say Mass in the chapel, but claim the authority of Jesus himself to justify their conclusion about the ethical course.

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About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.